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Entries in the 15th Annual ACHS Quality Improvements

Awards 2012

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Summary of entries Healthcare Measurement

Category: Healthcare Measurement QI Award

Submissions

15th

Annual ACHS Quality Improvement Awards 2012 Page 1 of 21

Project Title

CHINESE DIABABE PROGRAM Name of EQuIP Member Organisation

CANTERBURY HOSPITAL, NSW Department, Unit, Service or Group submitting the project

CANTERBURY HOSPITAL DIABETES EDUCATION – CAMPSIE Author/s Position Title Marita Ariola Clinical Nurse Consultant – Diabetes

Aim

To promote healthy lifestyle and the maintenance of a healthy weight to Chinese women who had Gestational Diabetes Mellitus (GDM) during pregnancy.

Abstract

Chinese Diababe Program was aimed at promoting the message of healthy lifestyle and the maintenance of a healthy weight for Chinese women who had Gestational Diabetes Mellitus (GDM) during pregnancy. The project lasted for 3 months.

Application of EQuIP Principles Consumer / Patient Focus

Diabetes is one of the identified priority health issues in the SLHD Multicultural Health Service Model of Care in 2010. 50.4% of the SLHD population are non-English speaking and ethnicity is a particularly importance factor in determining an increase in GDM. The prevalence of diabetes has doubled over the last 20 years and with an increased population, the actual number of people with diabetes has trebled.

Effective Leadership

The project was organized with Canterbury Hospital, Chinese Multicultural Officer, Chinese Australian Services Society (CASS) and Campsie Library and promoted through Chinese Media, community organisation, local councils and Chinese groups and Chinese Australian Services Society’s website. Guest speakers from Canterbury Hospital and Punchbowl Community Centre provided education sessions, which were in Mandarin. Pre and post questionnaires were distributed at the first and last session.

Continuous Improvement

The increase in GDM presentation is evident in Canterbury Hospital Ante Natal Clinic.

Diabetes data is available through Australian Diabetes Council and population demographics is from the Census 2006. Figures are also available from NSW Health and ANZDATA.

Diabetes is a major cause of non- traumatic amputations in Australia and recently became the leading cause of the commencement of renal dialysis. Other factors are a major contributor to cardiovascular disease and a two to four-fold risk of heart disease. The cost of type 2 diabetes per person is $5000

per year and $9000 if both micro vascular and macro vascular complications are present ( Colagiuri et al, 2004).

The participants’ waistline and weight were measured at every session and the quick results encouraged participants to exercise regularly. Participants were keen to learn and attended every session. Chinese speakers made the topics more relevant and culturally appropriate and all handouts were in Chinese. Participants will be invited to meet again in 6 months to measure their waistline and weight. The “Swap It Don’t Stop It “booklets and diaries were used in each session and Healthy


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Food Fast cook book was given to the participants at the end of the last session. Participants were encouraged to go through the cook book and cook healthy meals for their family members. The three sessions also provided in formation for the new mothers on sleep and settling and baby development needs.

Evidence of Outcomes

Three sessions were held from October to December 2011 and a total of 32 people attended. The sessions were available to the patients with type 2 diabetes. 7 of the participants had GDM. 100% of the participants indicated that the program was useful 100% of the participants indicated that they felt confident in managing their diabetes after attending the program. 20% of the participants indicated that they would like to attend this program regularly to improve health knowledge. Verbal feedback received from one participant was she felt fitter and other participants stated that they had started choosing healthy food and exercised more.

Results were based on standardized outcome measures “waistline and weight”. Participants lost 1.8 cm off their waistline and 1 kg. in weight.

Striving for Best Practice

In order to raise awareness of the diabetes in the community an article about this project was published in The Torch – Canterbury’s local newspaper on the 7 December 2011. Participants from

The program will be followed up by the Diabetes Educator and another program is planned to commence shortly.

Innovation in Practice and Process

Due to the success of the program, there will be a general diabetes workshop for Chinese speaking people and there is also a follow up meeting regarding future diabetes workshops with diabetes educators.

Applicability to Other Settings

It is hoped that this program will not be exclusive to the Chinese Community and that mothers from Aboriginal, Torres Strait and Pacific Island, Indian sub-continent, South East Asian and Middle Eastern backgrounds will receive the message and maintain a healthy lifestyle.

This program is easily transferable to any District of NSW Ministry of Health. Currently there is no funding available for the program and this program was possible through the Chinese Multicultural Officer, Chinese Australian Services Society and Campsie Library who provided the venue and a notebook computer, data projector and white board for presentations. Speakers were provided free of charge by the SLHD.

References:

Colagiuri, S., Hussain, Z., Zimmet, P., Cameron, A., Shaw, J. (2004), Screening for type 2 diabetes and impaired glucose metabolism: the Australian experience. Diabetes Care. 27 (2).367-71.


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Project Title

ENHANCING PARENTING SKILLS FOR PARENTS WITH MENTAL ILLNESS: THE MENTAL HEALTH POSITIVE PARENTING PROGRAM (MHPPP)

Name of EQuIP Member Organisation CENTRAL COAST LOCAL HEALTH DISTRICT, NSW

Department, Unit, Service or Group submitting the project

CHILDREN AND YOUNG PEOPLE’S MENTAL HEALTH (CYPMH) Author/s Position Title

Ruth F Phelan COPMI Coordinator

Deborah J Howe Director, Children and Young People’s Mental Health (CYPMH)

Emma L Cashman Research Officer

Samantha H Batchelor Team Leader

Aim

To determine the effect of the Mental Health Positive Parenting Program (MHPPP) on parenting practices of parents reporting a mental health problem.

Abstract

Objective: To determine the effect of the Mental Health Positive Parenting Program (MHPPP) on parenting practices of parents reporting a mental health problem. Design, setting and participants: A prospective before and-after examination of positive parenting skills and parent-reported child outcomes among parents of children aged 2–10 years who had self-reported a mental health problem. One hundred and eleven (85.4%) of 130 parents who commenced the MHPPP completed the program. Of these, 77.5% (n = 86) completed both before and after intervention measures. The MHPPP was conducted across Four community health centres.

Intervention: A 10-week intervention was tailored to parents with a mental health problem. The intervention was divided into a 6-week group parenting program based on the Positive Parenting Program and four weekly home visits. Main outcome measures: Parental discipline practices and children’s behaviour were measured by the Parenting Scale (PS) and the Eyberg Child Behavior Inventory (ECBI), respectively. Results: Following the MHPPP, parents scored significantly lower on each of the PS subscales:

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Conclusions: Our findings suggest the MHPPP can reduce the number of dysfunctional parenting strategies and parent-reported child behavioural problems. The MHPPP is a promising avenue for early intervention in this population.


MHPPP consumers’ self-identity parenting issues and acknowledges the impact of their mental illness on their parenting.

The MHPPP considers the parenting needs of consumers in the context of their mental health.

The MHPPP was evaluated by comparing the parent/consumer’s rating of their parenting skills and children’s behaviour before and after the MHPPP.


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The MHPPP facilitators endeavored to be as flexible as possible with the program particularly with regards to the scheduling of groups, the pre-interview and home visits.

The MHPPP was offered in two Local Government Areas to help ensure equitable access for all parents with mental illness living on the Central Coast.

Evaluations of the MHPPP were performed regularly to ensure that the program continued to effectively meet the needs of the consumers/parents.

A consumer/parent satisfaction survey administered at the end of the program suggests that nearly all consumers/parents (97%) received the help they wanted and reported an improved ability to deal with child and family problems (98%), with 87% indicating that the MHPPP had positively impacted on their mental health.

Effective Leadership In recognition of the lack of support available for parents with mental illness and the limited

number of parenting programs, Children and Young People’s Mental Health adopted parenting as a priority prevention portfolio.

This program has been developed and driven by Children of Parents with a Mental Illness (COPMI) staff in recognition of the high number of children (23%) who live in a house with a parent who has a mental illness and the mounting evidence of poor outcomes in children who have parents with mental illness (Berg-Nielsen et al., 2002; Maybery et al., 2009).

Designated positions receive training and support to ensure ongoing quality in program delivery.

Continuous Improvement Each MHPPP group is evaluated. The information collected includes:

o Demographic and client information; o Referral information; and o Pre and post MHPPP evaluation.

The regular evaluations have led to several improvements to the MHPPP for the consumers/parents. For example, after 6 months of running the program, the “pre-interview” was introduced to increase consumers/parents engagement with the program and also to ensure the baseline measures were collected.

The ongoing evaluation also extends to reviewing the referral avenues to try and improve the access and equitability for parents who want to participate in the program.

Service development has also focused on improving feedback to referring agencies and/or consumer supports.

Program data collection and management is also reviewed regularly for quality improvement.

Evidence of Outcomes Program The MHPPP is a 10-week intervention adapted from the Triple P for parents who have mental health problems. The MHPPP consists of a 6-week group parenting program followed by four weekly home visits. Participant criteria Participants were eligible if they were parents of children aged 2–10 years and self-reported a mental health problem. Sample Between July 2005 and February 2011, 23 groups undertook the MHPPP in four community health centres across two local government areas. In total, 130 parents commenced the program and 111 (85.4%) parents completed the program. Of the 111 parents who completed the program, 86 (77.5%) completed both the before- and after-MHPPP measures. The following data reports on these 86 participants. Measures The Eyberg Child Behavior Inventory (ECBI) was used to measure parent perceptions of behavioural problems in their children. The 36-item questionnaire comprises two subscales, which assess the frequency in which the behaviour occurs (intensity subscale) and its identification as a problem


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(problem subscale). The intensity subscale requires parents to indicate the frequency with which each behaviour occurs, using a 7-point Likert scale ranging from 1 (never) to 7 (always). Scores range from 36 to 252, with higher scores indicating greater frequency of behaviour. Intensity scores > 132 are considered to be in the clinical range. The problem subscale requires the parent to indicate whether a behaviour is currently a problem for them (1 = yes, 0 = no). Scores range from 0 to 36, with higher scores indicating a greater number of child behaviour problems. Scores > 15 on the problem subscale are considered to be in the clinical range (Eyberg & Pincus, 1999). The Parenting Scale (PS) is a 30-item self-report measure that assesses parent discipline practices. The PS requires parents to indicate their tendencies to employ each of the discipline strategies on a 7-point Likert scale from 1 (high probability of selecting an effective discipline strategy) to 7 (high probability of selecting an ineffective discipline strategy). PS scores above 3.2 for laxness, 3.1 for over-reactivity and 4.1 for verbosity are considered to be in the clinical range (Arnold et al., 1993). The Parent Satisfaction Questionnaire (PSQ) The PSQ is a 16 item questionnaire developed by the Triple P to assess parents overall satisfaction at the end of the intervention. Items addressed parent’s perceptions regarding the type, amount and quality of the service; how well the program met both the needs of the parent and child; and whether the program helped parents develop skills and effectively manage their child’s behaviour. Procedure After parents were referred to the MHPPP, they were encouraged to attend an interview at their home or a community health centre to discuss the MHPPP and complete the preprogram measures. At the end of the MHPPP, on the final home visit, participants were encouraged to complete the post program measures. The measures chosen were based on recommendations from the Triple P. Analysis Statistical analysis was undertaken using SPSS version 19.0 (SPSS Inc, Chicago, Ill, USA). Comparisons of sample characteristics were performed using 2 tests and independent-sample t tests. Due to the skewness of some of the outcome variables, within-group comparisons were assessed using Wilcoxon signed rank tests with critical level set at 0.005 (i.e., Bonferroni adjustment of 0.05/10). A series of McNemar’s tests were performed to examine the number of parents scoring in the clinical range on each of the outcome variables before and after the MHPPP. Results-Quantitative Following the MHPPP, parents reported significantly less dysfunctional parenting on each of the PS subscales and significantly less child behaviour problems on both ECBI subscales. Furthermore, the number of parents who scored in the clinical range prior to the MHPPP was significantly reduced across all outcome measures following the program. Results-Qualitative Qualitative measures (PSQ) indicated that parents regarded the MHPPP as beneficial with positive outcomes extending to their mental health and relationships with their children and partner. Specifically:

97.3% reported receiving the type of help they wanted;

98% indicated that the MHPPP had improved their ability to deal more effectively with their child and family problems, with over half rating the program as improving their relationship with their partner; and

87% indicated the MHPPP had positively impacted on their mental health.

Implication CYPMH were successful in developing an innovative and effective parenting program designed specifically to assist parents with a mental illness who have young children. The MHPPP is a promising avenue for early intervention in this population with benefits that extend to the entire family in regards to improvements in their relationships, behavior, parenting and mental health.


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Striving for Best Practice

CYPMH adopted the evidence-based Triple P program and ran it as a pilot program for parents with mental illness. However, after consideration of participant and facilitator feedback, the program was tailored to suit parents with a mental illness and thus became the MHPPP.

Since the development of the MHPPP it has been published in two scientific journals (Phelan et al., 2006; Phelan et al., 2012) most recently in a 2012 supplement for the Medical Journal of Australia (MJA) about parental mental illness. This process involves a comprehensive review of the latest evidence, a formal analysis of all participants and peer-review by statisticians and academics who are experts in the area. As a result of the suggestions from the MJA peer-review, the MHPPP now collects additional information about parent characteristics, includes a measure of psychological distress and is evaluated by more sophisticated statistical analyses, all of which were done to improve the quality of the MHPPP.

The latest evaluation of the MHPPP published in MJA is available on both the National COPMI website as a Clearinghouse Item (http://www.copmi.net.au) and included on the Australian Government’s Australian Institute of Family Studies library database (http://www.aifs.gov.au/cfca/bibliographies/mentalhealthparent.php). Recognition from such esteemed sources demonstrates that the MHPPP is meeting best practice recommendations and contributing to the emerging evidence with regard to COPMI interventions.

Innovation in Practice and Process

In Australia, about 23% of children live in households where at least one parent has a mental health issue (Maybery et al., 2009). While many parents with a mental illness are able to cope well with parenting and some children show little, if any, adverse outcomes, there is a strong association between parental mental illness and poor outcomes in children (Berg-Nielsen et al., 2002; Falkov et al., 2002). Many parents with mental health problems are reluctant to seek help because of the stigma that surrounds mental illness. This stigma is often associated with the fear of custody loss and can keep parents from acknowledging problems, particularly in relation to parenting and requesting services (Ackerson, 2003; Hearle et al., 1999; Nicholson, 1996).

In 2004, CYPMH recognized the lack of support for parents who have mental illness and young children and piloted the Positive Parenting Program (Triple P) level four group program. Of the interventions targeting family relationships and parenting in families, behavioural family interventions founded on social learning models have the greatest empirical support (Patterson, 1982; Sanders, 2002). The Positive Parenting Program (Triple P) (Sanders, 1999) is a well-established behavioural family intervention that has been successfully adapted to a number of different populations. Following suggestions and recommendations from clinicians and parents with mental illness who completed the Triple P, the program was modified and consequently the MHPPP was developed. The MHPPP is an adaptation of the Triple P tailored to the needs of parents with mental illness who have young children. It retains the four fundamental sessions and incorporates an additional two sessions and four weekly home visits. Applicability to Other Settings In early 2012, an evaluation of the MHPPP was published in the Medical Journal of Australia’s National COPMI Supplement. Subsequently, the paper has been added on the National COPMI website and included in communications, such as the COPMI e-newsletter. Acknowledgement by such esteemed resources enables the effectiveness of the MHPPP to be disseminated at a national level to health services and professionals. All NSW health services have a commitment to early intervention and prevention principles and the MHPPP could be easily adopted by other health services that have staff trained as Triple P facilitators and a willingness to learn the additional components. Alternatively, working in collaboration with other government/non-government agencies that already provide Triple P can reduce the load on health services. Further, the core Triple P is a well-established behavioural family intervention that has been successfully adapted to a number of different populations such as overweight and obese children, Indigenous families and working parents.

http://www.copmi.net.au/

http://www.aifs.gov.au/cfca/bibliographies/mentalhealthparent.php


Submissions

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Project Title

IMPROVING ACCESS TO TIMELY QUALITY HEALTH CARE Name of EQuIP Member Organisation

SOUTHERN NSW LOCAL HEALTH DISTRICT Department, Unit, Service or Group submitting the project

HEALTH INFORMATION DEPARTMENT, COOMA HEALTH SERVICE

Author/s Position Title Margaret Hoey Health Information Manager – Cooma Health Service

Aim

To introduce Quality Activities to improve better patient outcomes and to review the services provided to patients on discharge from the hospital.

Abstract Monthly reports prepared by the Health Information department at Cooma Hospital, including ‘Avoidable Admissions’. ‘Unplanned readmission within 28 days’ and ‘Outliers’ are reviewed by the members of the Hospital’s Clinical review Committee on a monthly bases. Recommendations made for improved patient care.

Application of EQuIP Principles Consumer / Patient Focus Selected patient’s medical records are reviewed by the members of the Clinical Review Committee with recommendations for improved patient care and/or improved Community Services for the discharged patient

Effective Leadership Both Medical and Nursing staff at Cooma Hospital are involved with the discussions and recommendations made at the Clinical review Committee. . These recommendations are also endorsed by the Health Service Manager.

Continuous Improvement Inclusion of these reports as a standing item on the AGENDA of the Clinical Review Committee.

Evidence of Outcomes Improved services for the discharged patients.

Striving for Best Practice Correct allocation of DRG’s pertaining to correct Service categories during Hospital stay. Will result in correct data being submitted for future introduction of ABF at Cooma. Identification and recommended improvements of any Community Services made available for the discharged patient.

Innovation in Practice and Process Review and discussions held one week prior to Clinical Review Committee meeting.

Applicability to Other Settings Expand the review to different DRG lists and increase audits to improve documentation in the patient’s medical record.


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Project Title

IN THE PATIENT’S SHOES: THE EASTERN HEALTH PATIENT EXPERIENCE OF CARE PROGRAM

Name of EQuIP Member Organisation

EASTERN HEALTH, VIC Department, Unit, Service or Group submitting the project

QUALITY, PLANNING & INNOVATION

Author/s Position Title Tanya Hendry Manager Consumer Participation & Patient Experience

Jo Gatehouse Director Quality Planning and Innovation (Acute Health and Consumer Participation & Patient Experience)

Aim

To better understand and respond to the experiences of consumers and carers who use Eastern Health’s services and to embed consumer and carer feedback into Eastern Health’s continuous

improvement approach. Abstract

Eastern Health is committed to improving the patient experience. In order to understand and respond to the experience of our consumers and carers, it was essential that we establish a framework for measuring and trending the patient experience. The In the Patient’s Shoes framework (see appendix 1) outlines a number of strategies that Eastern Health implements to receive consumer and carer feedback. The main feedback strategies currently being implemented are:

1. Patient Experience Trackers (PETs) - The PET is a handheld mobile device that electronically

collates responses to five questions about patient experience. PETs have been used to capture patient experience data across all inpatient wards as well as specific questions being developed for programs such as: Women’s & Children’s; Turning Point Drug & Alcohol; Emergency Department; Food Services; Hospital in the Home; Transition Care Program; Aged Care Assessment Service; Victorian Paediatric Rehabilitation Service and Hospital Admission Risk Program.

2. Leadership Walkrounds – since June 2011 senior leaders have conducted walkrounds at all

sites on a bi-monthly, monthly, fortnightly or weekly basis to actively hear about the care that patients are experiencing. Walkrounds provide meaningful qualitative data and are an opportunity for senior leaders to highlight to patients and employees that they are committed

to the strategic direction of ‘A GREAT patient experience’.

3. Victorian Patient Satisfaction Monitor (VPSM) - The VPSM is a survey conducted by the Department of Health and is designed to determine patient satisfaction with major aspects of health care service delivery in Victorian hospitals providing acute and sub-acute care. Eastern Health receives the results of this survey bi-annually.

4. Patient Feedback – complaints and compliments data

5. Meal Services Survey – patients are asked to complete a detailed survey about meals and

the results of this are collated monthly. The implementation of other strategies outlined in the framework is underway to provide further richness to the data being collected currently.


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Since July 2011, all data collected from the above feedback strategies has been themed against 10 EH Patient Experience of Care standards (see appendix 2), allowing the organisation to identify areas of strength and opportunities for improvement. Quarterly Patient Experience of Care reports are provided to the Program Quality and Strategy Committees, Clinical Executive Committee, Community Advisory Committee and Board Quality Committee and published on the intranet for all staff to access. In April 2012, data over a nine month period was analysed to identify ongoing areas where improvements are needed. Some of the key areas identified include:

Communication and customer service Use of interpreters Patient experience in relation to food services.

Application of EQuIP Principles Consumer / Patient Focus The In the Patient’s Shoes program has been established to meet Eastern Heath’s strategic direction of ‘A GREAT patient experience’ and highlights the organisation’s commitment to consumer participation in the planning, delivery and evaluation of the services provided. The feedback strategies evaluate the service from a consumer and carer perspective and the quarterly reports use quotes from consumers and carers to give staff a meaningful sense of the patient voice. Gathering data through these strategies demonstrates that the organisation understands the needs of the consumer and places utmost priority on their needs. Patient feedback is central to driving improvements to the systems of care.

Effective Leadership The fact that ‘A GREAT patient experience’ is one of Eastern Health’s five strategic directions for 2010-15 indicates that the organisation’s leaders consider this as an area of significance. The Chief Executive Officer regularly mentions ‘In the Patient’s Shoes’ in his fortnightly bulletin to all staff and has included increased patient and family satisfaction as one of his 10 key performance indicators for 2012. In late 2010 the Centre for Patient Experience was developed and a new position - Manager, Consumer Participation & Patient Experience, was developed and recruited to in order to assist Eastern Health to hear the voice of the consumer and respond to feedback in a meaningful way.

Continuous Improvement One of the main aims of this program is to embed consumer and carer feedback into the organisation’s continuous improvement approach. Presenting quarterly reports with recommendations based on this feedback to the Executive, Board Quality and Community Advisory Committee highlights the organisation’s commitment to using this feedback to inform quality improvements.

Evidence of Outcomes Theming the data against the 10 patient experience of care standards demonstrates the organisation’s commitment to achieve a great patient experience. Reports are provided to key committees to monitor that the standards are being met and identify areas for improvement.

Striving for Best Practice In developing the 10 ‘Patient Experience of Care Standards’, the Patient Experience of Care Expert Advisory Committee took into consideration:

Feedback received via the various patient feedback strategies available across Eastern

Health The Eight Picker Principles of Patient-Centered Care which were developed using a

wide range of focus groups—recently discharged patients, family members, physicians and non-physician hospital staff—combined with a review of pertinent literature, researchers from Harvard Medical School, on behalf of Picker Institute and The Commonwealth Fund

Victorian Patient Satisfaction Monitor elements (which form part of the Statement of Priorities for the organisation)


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Literature review related to the components and definition of ‘Patient Centred Care’ Feedback from the Eastern Health Community Advisory Committee members The Australian Charter of Healthcare Rights in Victoria Cultural Responsiveness Framework, Department of Health Victoria, 2009 The Australian Safety and Quality Healthcare Accreditation Scheme National Standards

Innovation in Practice and Process Eastern Health believes that the ‘In the Patient’s Shoes’ program is an innovative approach to collecting and using consumer and carer feedback to inform improvements. We believe that we are a leader among other Victorian health services in this area and know this from the feedback received when we have presented our program at various forums and conferences.

Applicability to Other Settings We believe that our program can be applied to other health care settings. As mentioned above, we have presented our program at numerous other forums and conferences and often receive requests from other health care services about the program and specific strategies we are implementing. Eastern Health has been open with sharing their methodologies and learnings from the development of this program and hope that through this we have contributed to a great patient experience at other Victorian health services, not just our own.


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Project Title

HIGH FIVE: HIGH VOLUME AND HIGH COST DRG PROJECT Name of EQuIP Member Organisation

ILLAWARRA SHOALHAVEN LOCAL HEALTH DISTRICT Department, Unit, Service or Group submitting the project

WOLLONGONG HOSPITALS AND COMMUNITY HEALTH SERVICE Author/s Position Title

Alexander Smeaton ISLHD Clinical System Manager

Merrilyn Morris ISLHD DRG LOS Facilitator

Aim To save 800 bed days across the district in our top five high costs and high volume DRGs and improve the clinical content in the medical records within our district.

Abstract Health Round Table (HRT Data for ISLHD hospitals identified that some Diagnosis Related

Groups (DRG) had higher length of stay and lower complexity levels compared to peer facilities

A redesign team reviewed the top five high volume and high cost DRGs with the aim of developing long term strategies to promote quality care in an equable and timely manner

Following a review of clinical documentation, it was identified that there was: o no models of care o poor clinical content of medical records o sub-optimal discharge summaries

To address this problem, evidence-based documented models of care, a discharge summary template and real time education package on clinical content of medical records were introduced. As a result, Length of Stay (LoS) has reduced.


A high level of patient focus has been demonstrated in this project, which involved the redesign of models of care for patients admitted in the selected DRGs

Clinicians’ engagement was vital throughout the redesign and implementation process and is an ongoing priority for the future sustainability of the project.

Effective Leadership Executive Management support direction and commitment to this project has been imperative Reporting to Executive Management on progress of the project has been consistent and

necessary for ongoing development and sustainability The project team consisted of 3 FTE with extensive clinical and Health Information expertise.

Continuous Improvement This project used NSW Health Redesign Model methodology to improve performance and

develop effective models of care.

Evidence of outcomes Third quarter results have indicated bed day savings of 678 and an increase in the complexity

levels of our patients. The bed day saving are on trend to meet our original full year target of 800.


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Striving for best practice HRT 2010/2011 data identified that at Wollongong (TWH), Shellharbour (SHH) and

Shoalhaven (SDMH Hospitals, some DRGs had significantly higher LoS and lower patient complexity levels compared to other HRT members

Substantial bed day savings could occur if we moved towards our peer hospitals LoS and accurately captured patient’s complexity levels

New efficient models of care have been developed on best practice.

Innovation in Practice and Process Illawarra Shoalhaven local Health District is one of the first districts to undertaken a review of

its high volume and high costs DRGs and develop new efficient models of care for these DRGs.

Applicability to other settings The three main components of the project can be transferred to any local health district within

NSW Bed day savings gained and capture of true patient complexity level as demonstrated by this

project will be vital in an ABF healthcare environment.


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Project Title

LIVERPOOL EMERGENCY SEPSIS TROLLEY


LIVERPOOL HOSPITAL, NSW


EMERGENCY DEPARTMENT

Author/s Position Title

Matthew Smith Staff Specialist

Anielka Dimakis Registered Nurse

Diane Burton Nurse Manager Emergency

Richard Cracknell Director of Emergency

Aim Reduce time to empirical antibiotics for septic patients and safe storage of restricted antibiotics.

Abstract Prior to commencement of the sepsis pilot October 2010 our time to antibiotics was 4.5 hrs. In January, 2011 with increased education and recognition, our time to first antibiotic was reduced to 2.5hours. For the period January to December 2011 average times remained static between 90 to 120minutes. We identified the need to further reduce time to antibiotics in order to meet the target of less than 60 minutes. It was hypothesized that by taking the antibiotic to the bedside the time to initiation of the first antibiotic would be reduced. The sepsis trolley was introduced in December 2011. By using the lockable trolley we had a solution for quicker administration of antibiotics and storage of restricted antibiotics which were part of empirical guidelines. The sepsis trolley would also provide a vehicle for cannulation and blood taking equipment.

Application of EQuIP Principles Consumer / Patient Focus Improve patient care by reducing time to antibiotics and potentially reducing morbidity and mortality caused by delays.

Effective Leadership Leadership is demonstrated through the promotion of the Liverpool Emergency Sepsis Trolley throughout NSW hospitals by the Clinical Excellence Commission. Staff are recognized for identifying septic patients.

Continuous Improvement Data is audited and reviewed daily for sepsis patients Meetings are held to discuss the trolley contents and usability. Teleconference meetings are held monthly with the CEC and hospitals within the state.

Evidence of Outcomes Improved time to antibiotics since the trolley has been introduced. Our mean time is now 59 minutes which is the under the 60 minute target and better than the state average

Striving for Best Practice We compare our data with the SWS LHD and NSW hospitals data. We use the NSW antibiotic guidelines and the sepsis pathway. Monthly meetings with the sepsis committee led by the CEC are attended.

Innovation in Practice and Process This is a new concept in storing and delivering the antibiotics.

Applicability to Other Settings This could easily be introduced at other departments and hospitals.


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Project Title

EVALUATION OF CONSUMER FEEDBACK PROCESS – CREATING A SUSTAINABLE MODEL FOR INCORPORATING CONSUMER FEEDBACK INTO QUALITY IMPROVEMENT


PENINSULA HEALTH, VIC


QUALITY AND CUSTOMER SERVICES


Jenni Dickson Quality Improvement Manager

Aim To develop a sustainable process for the integration of consumer feedback information to improve the consumer experience at Peninsula Health.

Abstract Collection of consumer feedback data commenced at Peninsula Health in 2005 with a ‘motel style’ card used in the sub-acute inpatient wards. In October 2008 the original motel slip was revised with feedback from consumers and rolled out across Frankston and rosebud Hospital inpatient areas. To assist the process of completing and collecting motel slips in Frankston Hospital volunteers were recruited and trained. The evaluation included survey of consumers about their understanding of the inpatient motel slip and ambulatory feedback card and the development of a Consumer Feedback Working Party. Outcomes of the Work Party:

A revised motel slip was implemented in March 2011 Volunteers targeted to specific wards rather than visiting all wards to assist patients complete

motel slips Reports revised to enhance readability and the reporting of comments by themes Ensuring Consumer Feedback is reported through the Quality Framework Expansion of the volunteer initiative to include sub-acute wards

Application of EQuIP Principles Consumer / Patient Focus The working party established to review the consumer feedback process included three consumers. The patient’s understanding of the motel slip was surveyed by consumers. The motel slip was approved by the Community Advisory Committee. The role of the volunteer was expanded to include sub-acute areas.

Effective Leadership Reporting structure for Consumer Feedback Reports were reviewed and refined to include:

Overall Peninsula Health report Cluster reports Individual ward reports with verbatim comments Overall Peninsula trended reports Themed Comments report

The Consumer Feedback reports are presented at the Quality and Clinical Governance Management Committee and then to the Board Quality Governance Management Committee.


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Continuous Improvement The process for Consumer Feedback has been continually improving since its implementation. In 2006 when there were 965 responses, to a point where, in 2011, there were over 8000 responses. Process changes have been ongoing to increase the response rate and ensure wards and departments are using consumer feedback to improve services. Wards have made significant improvements as a result of consumer feedback, including the Acute Observation Ward.

Evidence of Outcomes 1. The PH motel slip has been revised 2. A robust reporting structure has been developed to ensure consumer feedback is actioned 3. Education to wards and departments has ensured consumer feedback is actioned through

Departments Operational Quality Risk Management Plans 4. There has been an increase in consumers participating in PH Consumer Feedback.

Responses from Inpatients has increased 22% in the past year alone from 4110 in 2010 to 5276 in 2011. Responses from ambulatory patients has removed at around 3000 for the same period

5. Implementation of a Consumer Feedback Module Victorian Health Incident Management System (VHIMS) using the Riskman database in 2012.

Striving for Best Practice Developing a sustainable Consumer Feedback process has enabled Peninsula Health to further refine and validate the information available through the Victorian patient Satisfaction Monitor (VPSM), targeting particular areas for improvement. It has also allowed for analysis of reporting to use the data to effect change.

Innovation in Practice and Process As a result of continued growth in the response rates a review of the Consumer Feedback has commenced and is focusing on How to make consumer feedback sustainable. With a 22% increase in 2010-2011 the burden of data entry and reporting has prompted a further review. Peninsula Health commenced entering Consumer Feedback into the Victorian Health Incident Management System (Riskman database) and Consumer Feedback can now be linked to a Quality Improvement Activity. This has also enabled themed comment reporting – comments are themed on entry to the database and reported by theme and whether the comment was complimentary, non-complimentary or a suggested improvement. Peninsula Health is participating in a project with Riskman to develop iPad capability which will provide real time Consumer feedback data and ensure direct data entry input into the database. It is anticipated the volunteers will assist with this project which will be commencing later in 2012.

Applicability to Other Settings The Consumer Feedback process and measurement is applicable to a range of different healthcare settings. The Ambulatory Consumer Feedback was based on the inpatient model and then reviewed to suit ambulatory services. Other metropolitan health services have visited Peninsula Health to view the model of consumer feedback.


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Project Title –

CREATING A HEALTH MEASUREMENT STRUCTURE TO EMPOWER THE NURSING PROFESSIONS FOCUS ON QUALITY OF PATIENT CARE Name of EQuIP Member Organisation

PRINCESS ALEXANDRA HOSPITAL, QLD Department, Unit, Service or Group submitting the project

PRINCESS ALEXANDRA HOSPITAL NURSING SERVICES, METRO SOUTH, QUEENSLAND HEALTH EXECUTIVE DIRECTOR OF NURSING SERVICES CENTRE OF NURSING EXCELLENCE, CLINICAL PERFORMANCE, NURSING STANDARDS AND INNOVATION


Sandra Moss A/Nursing Director Centre of Nursing Excellence, Clinical Performance, Nursing Standards and Innovation Princess Alexandra Hospital (Project Manager)

Sarah Howarth A/Nurse Manager, State-wide Nurse Sensitive Indicator Program (Project Coordinator Phase 3)

Shannon Galletly Nurse Unit Manager, Brain Injury Rehabilitation Unit (Project Coordinator Phase 1 and 2)

Aim The project aimed to develop and implement a governance framework, standardising Nurse Sensitive Indicator (NSI) reporting to enhance public accountability for quality of care and patient outcomes throughout the state.

Abstract In 2009, the Nursing and Midwifery Office, Queensland (NMOQ) recognised an opportunity to support a project to investigate the reporting practices of nurses in relation to NSI, in order to develop the first state-wide facility level, standardised, automated adult hospital inpatient NSI reporting tool using existing Queensland Health (QH) systems. The first phase (September 2009-June 2010) of the State-wide NSI Project was highly successful with 89% of the 191 QH nominated facilities throughout the state’s 15 districts participating in a scoping survey. Survey results, literature reviews, workshops and widespread consultation enabled recommendations for an NSI suite. NMOQ and District Directors of Nursing and Midwifery Committee (DONMAC) endorsed the NSI suite.

Phase 2 (July 2011-June 2012) resulted in the development and evaluation of QH first standardised, automated monthly facility-level inpatient reporting tool, capturing patient outcome and workforce indicators that specifically relate to the nursing profession. The NSI Reports have been pilot trialled and evaluated within six (6) nominated QH facilities. The third and final phase (July 2012-December 2012) resulted in expansion of the NSI reporting tool from the initial 6 pilot sites to 114 QH Adult Inpatient Hospitals and modifications to the NSI Reports based on the pilot evaluation recommendations. Human and material resources required to support security governance and sustainability were developed. In addition, extensive consultation, collaboration and training was provided to over 200 QH staff. To maintain and progress the State-wide NSI Reports, the NMOQ recommended the development of QH first Centre of Nursing Excellence, Clinical Performance, Nursing Standards and Innovation to be developed at the Princess Alexandra Hospital (PAH). The Centre of Nursing Excellence was established in 2012.


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Consumer / Patient Focus The nursing profession is globally recognised as being instrumental in improving the quality of care delivery to improve patient safety. Ensuring nurses have access to relevant and reliable safety and quality data is integral to guide decision making about care delivery (Australian Commission on Safety and Quality in Health Care, 2010). NSIs are evidence-based measures that have a distinct relationship between the nursing input that is provided and the outcome delivered, for example hospital acquired pressure injuries (Doran, Mildon, Clarke, 2011). Yet, no standardized practices for capturing NSIs existed within QH. The NMOQ had a vision to develop a reporting structure to support clinicians evaluate nursing workforce and quality of care, in order to improve patient healthcare outcomes. In 2009-2011, a joint project initiative was undertaken between the NMOQ and PAH aimed to investigate NSI reporting practices in order to develop the QHs first adult hospital NSI reporting tool. The State-wide NSI Project developed a structure to measure patient outcomes to enhance public accountability and equip all organisations with a decision-making tool aimed to evaluate nursing’s contributions to healthcare service delivery. The resulting State-wide NSI Reports provide a suite of indicators that relate to the nursing profession and are designed to support nursing leaders throughout QH to monitor, analyse and compare data to inform strategic patient-focused quality improvement initiatives.

Effective Leadership In 2009, the NMOQ provided funding to the PAH to lead and manage the joint project initiative. A project team consisting of 2 nursing project positions was established. Additionally, a governance structure, which incorporated the Project Sponsor, Senior Suppliers, Senior Users, Project Assurance, Project Team and Collaborative stakeholders, was developed as the decision-making body that represented the interests of the key stakeholder groups. To determine the project direction a facilitated workshop was conducted on the 14th December 2009 with QH key stakeholders; including Executive Nursing Staff, Nurse Researchers and representatives from Centre for Healthcare Improvement and Clinical Practice Improvement Centre. The outcomes enabled the foundation for the project governance, scope, objectives and risks. The State-wide NSI Project was planned and divided into 3 distinct manageable stages including:

Phase 1: (September 2009–June 2010) Scoping QH Nursing and Midwifery Profession Phase 2: (July 2010–June 2011) Development of NSI Suite, NSI Report and Pilot Trial Phase 3: (July 2011–December 2011) State-wide Implementation.

To pursue ongoing development of strategies, systems and methods for achieving excellence, wide consultation and collaboration was undertaken with varied levels of nursing staff within all facilities throughout QH, state-wide and national collaborative groups, data source teams, universities, national and international database repository staff and QH stakeholders. This collaborative process contributed to the success of the project and encouraged engagement of QH employees to contribute

to innovative solutions for the development and implementation of the State-wide NSI Reports. The project team was supported by the Director of Nursing and Midwifery Advisory Committee (DONMAC); leadership committee which acts as the professional conduit for Health Service District Nursing and Midwifery services to provide collective advice to the Chief Nursing and Midwifery Officer on all nursing and midwifery related issues, structure and infrastructure (Queensland Government, 2012). DONMAC were committed to the project and nominated 1-2 district representatives from each district throughout QH to support the project team achieve deliverables and engage QH nursing to embed the NSI Reports into nursing practice.

The project team collaborated broadly with QH data source teams, State-wide Collaborative Groups and specialist staff to utilise their expert skills and knowledge to obtain lessons learnt from previous projects, obtain advice, enhance engagement and leverage support to achieve project proposals and outcomes. This resulted in the Director of QH Decision Support System (DSS) offering to create an innovative NSI platform, which has enabled 6 QH information systems and/or data sources to be linked and automated.


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The project team’s commitment to striving for excellence and encouraging employee contribution ensured the input from State-wide Collaborative Groups and specialist staff, which led to the development of: Targets, benchmarks and/or deviations from state and peer average to be used in the NSI reports

Data Specifications Data Security Memorandum User Guides NSI training.

The above strategies demonstrated effective leadership and ongoing commitment to excellence through investing in the learning and development of staff, supporting the change process and the sustainability of using NSI data to inform patient safety and nursing quality of care. Continuous Improvement The Project Team used a continuous quality improvement cycle (Plan-Do-Study-Act) to improve everyday practice. Extensive planning was undertaken throughout all phases of the project. Prince 2 project methodology was utilised to support in-depth planning and ensure delivery of outcomes. To determine ways to improve, a scoping survey was undertaken of 191 facilities throughout QH to explore existing NSI reporting practices, resources and data management. 135 staff who possessed skills, knowledge and experience with their facilities reporting tools and processes participated in the survey, conducted over 4 weeks, and obtained an 89% response rate. The results of the scoping survey identified an opportunity to support facilities to align with QH Strategic Plan and National Safety and Quality Health Service Standards to monitor nursing quality performance to improve patient outcomes. Recommendations and proposed strategies to enhance the quality of NSI reporting and practices included the development of:

Standardised evidence-based NSI suite Automated NSI reporting system Equity of access to the NSI Reports throughout QH Resources to support understanding of NSI suite and NSI Reports.

In compliance with the quality cycle, a pilot evaluation of the NSI suite, NSI Reports and Data Specification was conducted within 6 QH hospitals throughout January - February 2011 including: Cairns, Gympie, Longreach, PAH, the Prince Charles and Townsville Hospitals. Survey outcomes demonstrated statistically significant improvement and recommendations informed further enhancements to the NSI reports. This included the development of:

Peer Group performance comparison Best in peer group performance Training recommendations for state-wide implementation Future recommendations for additional NSI modules.

To continually strive to improve the quality of care by enhancing patient safety and accountability and inform strategic decisions at the nursing leadership level a hospital quality governance process for NSI reporting tool was developed.

Evidence of Outcomes Respondents identified that significant human resource hours from 2 hours to 2 days by nurse clinicians were lost due to manual data entry processes each month. This project has resulted in the development of a semi-automated system through interfacing and/or connecting 6 existing QH Information Systems or Data Sources to auto-populate the State-wide NSI Reports. The project has used existing QH systems to develop NSI Reports and enhance human resource efficiency, as they require no clinician hours to populate the tool. This equates to an estimated saving of $6,016.50 – $45,725.40 for QH each month.


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The scoping survey results identified that only 8% of participants strongly agreed existing reports were in a user-friendly format. Statistically significant improvements have resulted from the development of 5 user-friendly reports. The State-wide NSI pilot evaluation survey identified that an average of 96% of Nursing Executive agreed or strongly agreed that all NSI reports developed by this project were in a user-friendly format allowing easy interpretation of data. The scoping survey resulted identified that 66% of respondents stated there were no tools in place to enable staff to understand how to interpret data within their reporting tools. The Project Team have developed a Data Specifications which clearly explains 50 indicator measures, rational and link to patient safety. The pilot survey evaluation results identified that enhanced understanding of NSI has been achieved through the development of NSI Data Specifications with evaluation results showing that 100% of Super Users agreed information modules were relevant and informative.

For the first time QH Nursing Profession is able to compare facility, peer and state performance through standardisation of the State-wide NSI Reports. During the initial scoping survey conducted in Phase 1, it was recognised that rural settings had limited reporting practices in place and/or lacked the resources to develop or populate reporting tools. Phase 3 of the State-wide NSI project resulted in the implementation of the NSI reports to 114 adult inpatient facilities throughout the state, providing nursing measures for the first time in many rural settings.

To support sustainability of NSI Reporting, the Project Team:

Obtained 100% district endorsement received from QH DCEO, DDON&M for facilities within their districts to release data from QH data sources, enabling their respective facilities to receive the NSI reports

Developed roles and responsibilities for new portfolio positions and sought and obtained nominations of 22 District Coordinators to provide security access governance of the NSI reports within respective districts, and 194 Facility Supers Users to access reports

Developed material resources surrounding security access, business rules and how to use the NSI reports in a quality improvement process

Co-ordinated the delivery of DSS NSI Training to two hundred and three (203) QH staff including: District Coordinators, Facility Super Users, State-wide Collaborative members and specialist staff.

The success of the State-wide NSI project has resulted in the development of QH first Centre of Nursing Excellence, Clinical Performance, Nursing Standards and Innovation, to progress the State-wide NSIs and empower the nursing profession to investigate and manage risk, uncertainties and complexities related to ongoing challenges of delivering optimal healthcare that is resource efficient and patient safety focused. In 2011, the NSI Project was an IPAA finalist for project outcomes achieved through phase 1 and 2, which provided the foundation for the 3rd and final phase and resulted in state-wide implementation. In July 2012, the State-wide NSI Project has been announced as an IPAA finalist for all phases, with winners to be announced in September.

Striving for Best Practice An evidence-based approach has been used throughout the project, which has incorporated examination of literature, workshops, survey evaluations, pilot, and use of expert personnel to provide advice and knowledge. The following section outlines the significant body of work, driven by best practice, completed by the State-wide NSI Project Team during the 2-year timeframe in the evidence-based outcomes delivered.

A literature review was conducted September – December 2009 which examined strategic

alignment of NSI in QH; data reporting processes and existing national and international benchmarking repositories

To understand existing QH NSI reporting practices an online survey tool was developed which incorporated 40 questions, disseminated to 191 QH hospitals and was open for a


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period of 4 weeks from 10th March - 7th April. The estimated completion time rates varied between 5-90 minutes.

The NSI suite was developed based on scoping survey results; review of international evidence; examination of international and national data repositories; alignment with national agenda item and strategic documents; and workshops with specialist staff. A criteria was applied to ensure the indicators were meaningful to clinicians, feasible to collect and actionable by informing quality improvement.

A Data Specifications, which incorporates the NSI suite and outlines indicator specification, was developed based on scoping survey evaluation results, international evidence, alignment with corporate systems and strategic documents.

The NSI Reports were developed for 6 pilot facilities that were selected based on geographical diversity, size and potential challenges to capture data. The NSI Reports and Data Specification Module were piloted and evaluated during January – February 2011 utilising a survey evaluation tool. Recommendations informed further enhancements to the NSI Reports and development of a peer group comparison group.

QH Change Management Framework provided the foundation for the development of a State Implementation Plan.

Innovation in Practice and Process Pioneering work has resulted in the development and implementation of QH first NSI dataset and supporting governance framework. The significance of project supports QHs nursing’s transition to Local Health and Hospital Network and aligns with the National Safety and Quality Health Service Standards in focusing healthcare services to deliver optimal health and patient outcomes that are resource efficient and financially sustainable. The State-wide NSIs reports contribute in closing the gap between nursing quality and patient safety throughout QH adult inpatient facilities. The project team addressed this disparity through delivering standardised, automated, evidence-based, resource efficient management tools and processes with common corporate-based data sources, which created the foundations for a single source of truth for QHs nursing quality and patient safety practice. This has strengthened the position of nursing in QHs to inform strategic quality decisions and enhance public accountability. Uniquely, the NSI project has positioned QH amongst world leaders due to the development of a governance frame work, standardising NSI reporting, improved resource efficiency, transparency and accessibility of information throughout QH to foster high standards in nursing quality to improve patient outcomes. Successful outcomes has resulted in the establishment of QHs first Centre of Nursing Excellence for Clinical Performance, Nursing Standards and Innovation at the PAH aimed to sustain and further progress the NSI reports, promoting the quality of QHs nursing profession to improve patient safety.

Applicability to Other Settings The State-wide NSI reports align with the National Safety and Quality Health Service Standards providing an effective governance and management system to minimize risk. Longitudinal data supports healthcare facilities and Health Service Districts to monitor, analyse and investigate numerous healthcare outcome indicators, which can be aligned with the organisations, risk management strategy, aimed to improve nursing quality, minimize and prevent patient harm and support a culture of safety. The importance of developing a standardised NSI reporting process has wide implications on patient safety, quality, policy direction, cost efficiency, information equity, reporting governance and accountability whilst enabling nursing contributions to be measured, recognised and valued. Outcomes obtained throughout evaluation phases have highly recommended application of NSI reporting in other specialties such as Mental Health, Community, Midwifery, Paediatrics and Aged Care. The NSI project has set the foundation for far wider implications for the nursing profession than will be immediately realised.


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References

Australian Commission on Safety and Quality in Health Care. 2010. Australian Safety and Quality Framework for Health Care. http://www.safetyandquality.gov.au/wp-content/uploads/2012/04/Australian-SandQ-Framework1.pdf Doran, D., Mildon, B., & Clarke, S. 2011. Toward A National Report Care in Nursing: A Knowledge Synthesis. http://www.nurses.ab.ca/carna-admin/Uploads/Knowledge_Synthesis_Report_Card.pdf Queensland Government. 2012. Nursing and Midwifery Advisory Committee (DONMAC). Nursing and Midwifery Office Queensland Homepage. http://qheps.health.qld.gov.au/nmoq/our_office/donmac.htm.

The Australian Council on Healthcare Standards (ACHS)

5 Macarthur Street Ultimo NSW 2007 Australia

T. 61 2 9281 9955 F. 61 2 9211 9633

E. [email protected] W. www.achs.org.au

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